<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset={$charset}">
</head>

<title>支援物資お届け依頼掲示板 - 0910.jp | 新規支援物資依頼フォーム</title>

<meta name="keywords" content="">
<meta name="description" content="">
<meta http-equiv="Content-Script-Type" content="text/javascript" />
<meta http-equiv="Content-Style-Type" content="text/css" />

<!--Favicon-->
<link rel="shortcut icon" href="{$base}/images/favicon.ico">

<!--CSS-->
<link rel="stylesheet" type="text/css" href="{$base}/css/layout.css"/>

<!--Javascript-->
<script type="text/javascript" src="{$base}/js/jquery.js"></script>
<script type="text/javascript" src="{$base}/js/common.js"></script>

</head>
<body>

{include file="../layouts/top_menu.tpl"}

<div id="wrap">
    {include file="../layouts/side_menu.tpl"}
	
	<div id="right">
		<h2 class="title">新規支援物資依頼フォーム</h2>
		<div class="contents">
{if isset($errors)}
    {foreach from=$errors item=error}
        {if isset($error)}<font color="#ff0000">{$error.message}</font><br />{/if}
    {/foreach}
{/if}
			<h3 class="cont_title">必要な支援物資を入力してください。</h3>
			<form action="/okute/request/confirm" method="post">
			<div class="cont_01">
				<label for="bushi">必要な物資：</label>
				<input type="text" name="req_content" id="bushi" class="input_01 spacer_mb5" value="{$data.req_content|escape}"/>
				<p class="txt_01 spacer_mb20">支援物資は複数の支援団体から送ってもらえるように、まとめて記載せず種類をわけて記載してください。<br /><a href="#">記載例はこちら</a></p>
				
				<label for="kazu">数量：</label>
				<input type="text" name="req_amount" id="kazu" class="input_01 spacer_mb20" value="{$data.req_amount|escape}"/>
				<p class="txt_02">届け先：</p>
				<p class="txt_03">{$shelter->prefecture|escape}{$shelter->area|escape}{$shelter->city|escape}{$shelter->district|escape}{$shelter->name|escape}</p>
				<p class="txt_01 spacer_mb20"><a href="{$base}/shelter/list">避難所(住所)の変更</a></p>
				
				<p>
				<label for="kinkyudo">緊急度：</label><br />
				{html_options name=severity options=$severity_opts selected=$data.severity id="kinkyudo" class="input_02 spacer_mb20"}
				</p>
				
				<label for="sonota">その他、連絡事項：</label><br />
				<textarea name="notes" id="sonota" class="textarea_01 spacer_mb40">{$data.notes}</textarea>
				
				<div class="buttons"><input name="button" type="image" src="{$base}/images/img_0910_r_01_btn_01_off.gif" onmouseover="this.src='{$base}/images/img_0910_r_01_btn_01_on.gif'" onmouseout="this.src='{$base}/images/img_0910_r_01_btn_01_off.gif'" title="申請内容の確認" />&nbsp;&nbsp;&nbsp;<input name="button" type="image" src="{$base}/images/img_0910_r_01_btn_02_off.gif" onmouseover="this.src='{$base}/images/img_0910_r_01_btn_02_on.gif'" onmouseout="this.src='{$base}/images/img_0910_r_01_btn_02_off.gif'" title="入力内容の消去" /></div>
			</div>
			<input type="hidden" name=csrf value="{$csrf}">
			</form>
		</div>
	</div>
	<div class="hr1"><hr /></div>
</div>

{include file="../layouts/footer_menu.tpl"}

</body>
</html>
